Healthcare Provider Details

I. General information

NPI: 1962799361
Provider Name (Legal Business Name): MANJOORSA PHYSICAL THERAPY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8411 QUEENS BLVD
ELMHURST NY
11373-3098
US

IV. Provider business mailing address

8411 QUEENS BLVD
ELMHURST NY
11373-3098
US

V. Phone/Fax

Practice location:
  • Phone: 347-968-8304
  • Fax:
Mailing address:
  • Phone: 347-968-8304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number027648
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AL MANJOORSA
Title or Position: PHYSICAL THERAPIST/ DIRECTOR
Credential:
Phone: 347-968-8304